Mustard Seed

                                                             MUSTARD SEED DAYCARE, LLC

                                                                     Childcare CONTRACT

 

Child’s Full Name________________________________________________________________

Gender: Male__Female___Age___Date of Birth________________________________________

Address:________________________________________________________________________

City_____________State_______Zip Code_________Home Phone________________________

School Name/Address/phone/Grade__________________________________________________

 

Mother’s Full Name_______________________________________________________________

Mother’s Address:_______________________________

City___________State______Zip Code_______Mother’s Home Phone______________________

E-Mail:_____________Cell Phone_______________ Social Media_________________________

Mother’s Employer:________________Mother’s Occupation______________________________

Employer’s Address:______________________________________________________________

Work Hours:____to___. Days at work:________________________________________________

Work Phone:________________________ext.__________

 

Father’s Full Name_______________________________________________________________

Father’s Address:_______________________________

City___________State______Zip Code_______Father’s Home Phone_______________________

E-Mail:_____________Cell Phone_______________ Social Media_________________________

Father’s Employer:________________Father’s Occupation_______________________________

Employer’s Address:______________________________________________________________

Work Hours:____to___. Days at work:________________________________________________

Work Phone:________________________ext.__________

 

Parent’s Marital Status:   Married    Separated              Divorced                Single         Widowed

Child resides with:  MOTHER OR FATHER (CIRCLE).

If Divorced, who has Legal Physical Custody_________________________.

May the Non-Custodial Parent Pickup Child from daycare  YES OR NO (CIRCLE).

 

Child Pick Up Form

The following people (other than parents/guardian) also HAVE permission to pick-up the child named above from Mustard Seed Daycare.  It is the parents responsibility to notify Mustard Seed in writing of any changes to this list.

Name____________________Phone#_____________

Relation:______________________

Address:_________________________________________________________________

 

The following people may NOT pick up my child/ren from Mustard Seed Daycare

 

Name________________________________________________

 

 

Emergency Contact Information

Primary Emergency Contact (other than parents/guardian):

Name______________________________________________________________________

Home Phone:_______________Cell Phone______________Work Phone________________

Emergency Contact Address_________________City___________State________

Relationship to Child:___________________________

 

Secondary Emergency Contact (other than parents/guardian):

Name______________________________________________________________________

Home Phone:_______________Cell Phone______________Work Phone________________

Secondary Emergency Contact Address_________________City___________State________

Relationship to Child:___________________________

 

Photo Release Permission

Mustard Seed occasionally uses photography/video for publicity purposes.  We would like your permission to photograph/video you/your relatives for possible inclusion in our publications, website and other publicity materials.  The image(s) will remain the property of Mustard Seed Daycare and will be used for the designated purpose of promoting Mustard Seed Daycare.

 

Name of Parent/guardian:____________________________________________________

 

I permit Mustard Seed Daycare to use photographs/videos of me/my relatives in the Mustard Seed publications and publicity and promotional materials.

Signed:_______________________________________Date:_______________________

 

Neosporin and Sprays Permission

I __________________________________give permission for the caregivers at Mustard Seed Daycare to apply topical ointments, spray on sun screen, and spray on bug spray to _______________________when they deem necessary.

Parent/Guardian Signature:____________________________Date:______________________               

 

Emergency Release/Consent to Medical Treatment

In a true emergency, a child may need to be treated without parental consent.  I hearby give my permission that in my absence, Mustard Seed Daycare providers may act on my behalf regarding the treatment of my child.  I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.  In the event that I cannot be contacted immediately and a delay would result in increased risk to the child’s life or health, medical or surgical treatment can be administered to my child as prescribed by a treating physician.

 

Parent/Guardian Signatures:________________________________________Date:_________

 

Mustard Seed Daycare will not be responsible for paying for the child’s health care.

• Child’s Physician_____________________________Phone:__________

• Insurance Company:________________

• Policy #______________Group#__________

• Regular Medications:_________________________________________

• Medicine Allergies_____________________________________________

• Food Allergies_____________________________________________

• Any other Allergies_____________________________________________

• Any Special health conditions:___________________________________________

 

This agreement is made by and between Mustard Seed Daycare LLC, Maryland State Department of Education (MSDE) Licensed Child Care Provider and ___________________, Parent/Guardian of ______________________. The following has been agreed upon between the two parties beginning __________________:

 

I agree to the weekly rate of $______________, to be paid the Friday before the week begins for my child/ren, _______________________. Our arrival time will be ____, and pick up time will be no later than 6pm_ From Monday through Friday. Any added time before or after those times will be subject to late pickup fees or early arrival fees. SEE PARENT HANDBOOK.

This agreement shall be in effect until which time parent/guardian has given a two weeks prepaid termination notice, or negotiation of a new contract. Provider reserves the right to void the contract without cause.

 

THIS AGREEMENT WHOLLY STATE THE OBLIGATIONS OF THE PROVIDER; THERE ARE NO OTHER IMPLIED OBLIGATIONS. ANY AMENDMENTS TO THIS AGREEMENT MUST BE IN WRITING AND SIGNED BY BOTH PARTIES.  I understand that this is a legally binding document.  I have read and understand all Mustard Seed Daycare Policies and Procedures.

 

___________________________________                                              ________________

Licensed Child Care Provider                                                                                              Date

___________________________________                                              ________________

Parent/guardian                                                                                                   Date

___________________________________                                              ________________

Parent/guardian                                                                                                   Date